HPV vaccination in LMICs: A thematic analysis of attitudes and implementation strategies

Objective To identify the attitudes towards the Human papillomavirus (HPV) vaccine amongst parents/guardians, the target population, healthcare providers and school staff in low-and middle-income countries (LMICs), and identify effective strategies to implement a HPV vaccination programme. Design This paper demonstrated a systematic approach to a literature review. Literature highlights a quantitative understanding of the low uptake of the HPV vaccine within LMICs. As such, this has provided a lacuna for a qualitative assessment of the attitudes towards the HPV vaccine, and consideration of effective methods to combat barriers within HPV vaccination programmes. Method Inclusion criteria consisted of studies conducted in LMICs from 2006 onwards, with a focus on attitudes amongst the stakeholders. Six databases and sources of grey literature were systematically searched. Leading critical appraisal tools were used to screen the literature for highquality evidence. Attitudes of acceptance and hesitancy were thematically analysed using a thematic framework. The final framework consisted of three domains of attitude of hesitancy and support;(1) Contextual factors, (2) Individual group influences and (3) Vaccine/Vaccination specific factors. Citation frequencies within each domain were visually presented. Effective implementation strategies were highlighted following a systematic literature review. Results Sixty-three papers from sixteen LMICs were included in the final review. Beliefs and attitudes about health prevention, religion/cultural factors, and perceived risks/benefits were common themes across attitudes of support and hesitancy throughout the four stakeholder groups. The trust of a healthcare professional was commonly reported amongst parents/guardians and the target population. Overall, hesitant attitudes received more citations than acceptance. This finding indicates the possibility of reporting bias, as hesitant attitudes were described with more detailed. Important vaccine delivery strategies include: a school-based delivery approach, an educational focus within outreach activities, and the collaboration of officials and community leaders. Conclusions The HPV vaccine receives mixed reviews across LMICs. Themes across the stakeholders centred around knowledge, sociocultural influence and exposure. Vaccine co-ordinators in LMICs should conduct a representative assessment of stakeholder attitudes prior to vaccine rollout. Outreach and sensitisation efforts should be prioritised with a focus on increasing knowledge about the vaccine, and vaccine activities should account for contextual needs by collaborating with respected influential individuals. This review was completed in 2018, however, important parallels can be drawn with the current climate in 2021 posed by the introduction of the COVID-19 vaccine.